Vouchers for sexual and reproductive health in Uganda

Young people most affected by HIV in Uganda have significant unmet sexual and reproductive health and rights (SRHR) needs. If health care providers are to improve their sexual and reproductive health, it is vital they create innovative ways to help them access high quality health services - such as these youth-friendly health vouchers, implemented as part of the Link Up project.

Unsafe sex places people at higher risk of sexually transmitted infections (STIs), including HIV, and unplanned pregnancy. This is particularly the case for young people living with HIV, teenage mothers, young people selling sex and LGBT young people (known as key populations), all of whom experience extreme difficulties when visiting public health facilities due to the high levels of stigma and discrimination, and in some cases, the fear of arrest.

Since 2013, Marie Stopes International Uganda and Community Health Alliance Uganda (our Linking Organisation) have been working together through the Link Up programme on exactly this issue.

Link Up built on Marie Stopes International’s wide experience of voucher schemes which they have used mainly to utilise the large but unregulated private sector by incentivising providers to deliver key health services at greatly improved standards, and to make them affordable.

The Link Up youthvoucher scheme was launched in March 2014. The aim was to both offer a choice of providers through partnerships with private health providers, but also high quality services which were sensitive to young people’s needs – particularly those from key populations.

The scheme

Vouchers (see above) allowed each young person two visits for HIV testing, three visits for family planning and three visits for STI management.

All services were free.

The vouchers were attractively designed – and included messages targeting young people. These were tested prior to production.

Vouchers were disseminated by 70 young people aged 17-26 who were trained as community-based distributors (CBDs). Not only were CBDs able to distribute the vouchers, they also offered health education and accompanied young people to the clinics if they wished.

CBDs were paid by the facilities for every voucher redeemed – with quarterly ‘mystery shopper’ or client verification exercises being conducted to ensure the authenticity of services claimed.

80 clinical officers and nurses from 40 health facilities and clinics were trained to work with young people who have sex and young men who have sex with men, including the use of appropriate language, their specific vulnerabilities, and how to refer them (e.g. for HIV treatment, gender-based violence support and the prevention of mother to child transmission).

Additionally, 44 young people from specific key population groups were trained, and then stationed at each health facility to welcome and assist young people during their visits.

Snapshot of results

Between March 2014 and March 2015, the Link Up voucher scheme in Uganda extended sexual and reproductive health and HIV services to nearly 30,000 young people.

The greatest uptake of services was for HIV counselling and testing (92%), STI management (75%) and family planning (37%).

There was a noticeable shift in family planning uptake – 51% receiving long-term family planning services and 49% receiving short-term family planning services.

The scheme was successful in reaching young people who sell sex (1,438), slum dwellers (4,188) and young people living with HIV (225). The presence of young people from key populations as both CBDs and as facility based volunteers was key.

However, young men who have sex with men were harder to reach. Marie Stopes International Uganda are trying to address this by improving their working relationships with Uganda’s MSM organisations, and further addressing the values transformation required among its staff.

The Link Up programme has produced a case study about the youth voucher scheme in Uganda. Colleagues from Marie Stopes International Uganda will be presenting the benefits of this approach at the International Family Planning Conference to be held in Indonesia, 25-28 January.

You can read about the inspirational impact of the work of Diana Amanyire, Head of Youth and Key Populations projects at Marie Stopes International Uganda in this blog.